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Certified Nursing Assistant

    Instruction

    Please rate your experience / frequency (within the last year) using the scale (check the appropriate boxes below)

  • 0 = No theory and/or experience
  • 1 = Limited experience/need supervision and/or support
  • 2 = Experienced/minimal support needed to perform)
  • 3 = Proficient/can perform independently
  • 4 = Expert/very experienced in the field
Personal Information

Full Name

Email

Phone number

Total years of CNA experience

Date

Age Specific Competency

Neonates/Newborns (0-30 days)

Infant (30 days-1year)

Toddler (1-3 years)

Preschool Child (3-5 years)

Older Child (5-12 years)

Adolescents (12-18 years)

Young adult (18-39 years)

Middle adult (39-64)

Older adult (64+ years)

Able to adapt care to age of normal growth and development

Able to adapt method and language to developmental age

Able to secure environment for safety according to developmental age

Computerized Charting

Standard Precautions/Infection Contol

Hand Cleaning Guidelines

Patient Confidentiality & HIPAA

Patient Safety Goals

Basic Skills

Double Bag Insolation Technique

Shave & Prep. Surgical Scrub

Standing Scale Weights

Bed Scale Weights

Linen Change: Occupied, Unoccupied

Monitor & Document & Output (I & O)

Special Diets: Clear liquid, Soft, NPO

Set-Up/Pass Meal TRays, Juice Water

Foley Care & Positioninh

Feeding Patients

Partial/Complete Bed Bath

Shower Sitz Bath

Oral Care

Peri-Scare

Enemas

Rectal Tubes

D/C Foley Catheters

Emptying & Recording Output

N/G Tubes

Hemovacs

Jackson-Pratt

T-tubes

Foley Catheters

Collecting Specimens

Urine, Stool

Sputum

Urine: sugar, Acetone, & Specific Gravity

Restraint Use, Safety, Requirements

Bedside Glucose Monitoring

Recognizing & Reporting Emergencies

Testing Stool For Occult Blood

Additional Skills

Ambulate, Resposition, & Turn Patients

Instruct Patients to Cough & Deep Breath

Use of Inncentive Spirometer

Instruct & Assist Patients With Leg Exercises

Put on/Taking OFF TED HOUSE/AVE Wraps

Use of Assistive Devices: Hoyer Lift

Decubitus Care

Range of Motion (ROM) Exercises

Ice packsK-Pads

CPM

Setting up of Post-Op/Admission Rooms

Answering Call Lights

Documentation of Care on Checklist Format

Application of Eggcrate/Geomat

Assist with Admission, Discharge, Transwer of Patients

Stocking/Ordering Supplies for Unit, Kitchen

Putting Patient Charts Together

Communicating with Other Staff Members About Patient Condition or Conplaints

Post-Mortem care

Restraint Safety and Guidelines

Obtaining and Charting Vital Signs

Blood Pressure

Pulse Rate, Apical

Pulse Rate, Radial

Respiratory Rate

Temperature, Axillary

Temperature, Oral

Temperature, Rectal

Temperature, Tympanic Digital

Notifying Staff of Abnormal Results

Certifications

CPR

Other

Please read and agree to the statements below by marking the checkbox.

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.

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